Ann Surg Treat Res.  2016 Feb;90(2):106-110. 10.4174/astr.2016.90.2.106.

Laparoscopic completion total gastrectomy for remnant gastric cancer following pancreaticoduodenectomy for bile duct cancer: a case report

• Kim DJ
• Kim W

• KMID: 2166830
• DOI: http://doi.org/10.4174/astr.2016.90.2.106

Abstract

Laparoscopic completion total gastrectomy following pancreaticoduodenectomy (PD) has not been reported. A 73-year-old male who underwent PD 25 years ago for distal common bile duct cancer visited a surgical department for remnant gastric cancer. A previous reconstruction was performed with pancreaticojejunostomy (PJ), gastrojejunostomy and Braun anastomosis, i.e., jejunojejunostomy (JJ), between the afferent and efferent jejunal limb to prevent bile reflux into the remnant stomach. Adhesiolysis was initially performed to secure the surgical view. Lymph node dissections around the splenic artery, splenic hilum, celiac axis, left gastric artery, and common hepatic artery were performed. The PJ site was well visualized and safely preserved. Esophagojejunostomy was performed with an OrVil system. Specimen retrieval, Roux-limb preparation and JJ were performed through an extended umbilicus trocar site. A final pathologic examination revealed a 5.5-cm serosa-exposed tumor (T4a) without lymph node metastasis. The patient was discharged on postoperative day 7 without any complications.

Keyword

Gastrectomy; Laparoscopy; Pancreaticoduodenectomy

MeSH Terms

Aged
Arteries
Axis, Cervical Vertebra
Bile Duct Neoplasms*
Bile Ducts*
Bile Reflux
Bile*
Common Bile Duct
Extremities
Gastrectomy*
Gastric Bypass
Gastric Stump
Hepatic Artery
Humans
Laparoscopy
Lymph Node Excision
Lymph Nodes
Male
Neoplasm Metastasis
Pancreaticoduodenectomy*
Pancreaticojejunostomy
Splenic Artery
Stomach Neoplasms*
Surgical Instruments
Umbilicus

Figure

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  Fig. 1 (A) Gastrofiberscope showing a 3 × 3-cm ulceroinfiltrative lesion at the greater curvature side of gastrojejunostomy. (B) Computed tomography image showing diffuse wall thickening at the greater curvature side of gastrojejunostomy (red arrow).

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  Fig. 2 (A) The patient underwent gastrojejunostomy and Braun anastomosis nearly 30 cm distal to the gastrojejunostomy site. (B) Gastrograffin swallowing test showing the remnant stomach and Billroth-II and Braun anastomoses.

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  Fig. 3 Trocar placement for the laparoscopic completion total gastrectomy.

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  Fig. 4 (A) Severe small bowel adhesion to the previous laparotomy wound. (B) Adhesiolysis with endo-scissors between the liver and remnant stomach. (C) Braun anastomosis located 30 cm distal to the gastrojejunostomy. (D) Overview of the remnant stomach, gastrojejunostomy, pancreas body, and spleen. (E) Total omentectomy was performed near the pancreaticojejunostomy. (F) The greater curvature side of the gastrojejunostomy exhibited no definitive serosal invasive lesion. (G) Lymph node dissection along the distal portion of the splenic artery. (H) Lymph node dissections around the celiac axis, proximal portion of the splenic artery, and left gastric artery. (I) Lymph node dissection around the common hepatic artery. (J) Anvil was introduced with a OrVil tube. (K) The Braun anastomosis was extracorporeally divided by linear stapler. (L) The jejunum was prepared for esophagojejunostomy with a circular stapler through the extended umbilicus trocar site. (M) Esophagojejunostomy performed under laparoscopic vision. (N) Esophagojejunostomy and post-lymph node dissection view along the splenic artery and hilum. (O) A hand sewing jejunojejunostomy was performed through the umbilicus port site.

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  Fig. 5 The resected specimen opened along the lesser curvature side revealed a 5.5-cm-long serosal-exposure gastric cancer without metastatic nodes among the 20 retrieved lymph nodes.

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